Emilie Couchman is an NIHR Clinical Lecturer in General Practice with the Division of Primary Care Palliative Care and Public Health at Leeds University, and a salaried GP with Sarum Health Group in Wiltshire. She has recently completed her PhD relating to continuity within the primary palliative care context.
An unnerving experience as a GP trainee made me reflect on the physical layout of my consulting room; specifically, whether I was closer to the door than the patient was. Metaphorically, though, I propose that the GP always ends up backed into a corner with no escape route, in comparison to other colleagues within the primary or secondary care context. A colloquial phrase, which I will not repeat here, essentially implies that issues originating among those at the top of a particular hierarchy tend to become the responsibilities of those further down the pecking order. Regardless of how complex, multidisciplinary, and fragmented the healthcare system becomes based on decisions made by people ‘at the top’; the GP is the one assuming responsibility, holding the risk, picking up the pieces, and is where the buck ultimately stops.1
We contain, hold, anchor, support, bind and carry; albeit with less time, money and respect. We cannot be conscientious objectors in the battle ground that is front-line NHS patient care.
I have been ruminating on a recent conversation with colleagues about a new scheme involving a geriatrician taking over a GP’s weekly care home ward round. The care home is still affiliated with the local GP practice, in that the patients are registered on its list. My initial reaction was: ‘That’s great! Specialist involvement to improve patient care’, which likely reflects the ‘specialists are superior’ stereotype that society subconsciously fuels. It is clearly engrained if this is my automatic reflex, as a staunch advocate for generalism. My colleagues and I then started to think about the practical logistics of this new arrangement, and the potential impact on interprofessional dynamics. For instance, what if the geriatrician makes clinical decisions during a ward round, and delegates the leg-work to the GP practice team? It would not be the first time that GPs have been made to feel like the junior doctors of specialists. Are we not perpetuating the bias that specialism supersedes generalism, and denigrating the value of GPs, by continuing to champion being overtaken rather than blowing our own trumpets? Do we need external specialists or multidisciplinary colleagues to fill such roles, or do we simply need more resources so that we can do the job we are proficient to do, to the high standard that patients deserve?
The RCGP’s updated definition of a GP advocates the use of the term ‘consultant in general practice’.2 Polarised perspectives are held among the GP workforce about this change, but perhaps the longstanding underappreciation of the generalist skillset, which is difficult to quantify and articulate, has provoked this response.3 Our job has always involved managing risk, uncertainty and complexity, but it is assumed that specialists will unquestionably add value by swooping in wearing capes and their underpants over their trousers. For those who love an analogy; imagine the scene. A father dons a tiara and is plastered in haphazard lipstick while engaging in princess role play with his daughter for ten minutes, after having watched 78 minutes of a football game on his iPhone in the bathroom. Observers may shower him with praise at his ‘dadding’ skills. Meanwhile, the mother silently (or passively-aggressively, perhaps) carries the mental load, day in, day out. However, she is overlooked, taken for granted, or maybe even chastised for her terse manner. (Disclaimer: this is in no way reflective of the author’s personal life; she heard about this phenomenon from a friend.)
Ultimately, whenever a spark of an ‘us versus them’ approach, across the primary-secondary care interface appears, it must be extinguished.
Given the resource limitations of the wider healthcare system, GPs are less and less able to refer tricky patients to specialist services, and so we continue to do what we have always done. We contain, hold, anchor, support, bind and carry; albeit with less time, money and respect. We cannot be conscientious objectors in the battle ground that is front-line NHS patient care. Our shoulders must remain broad, despite the atrophic impact of more complexity, more quantity and fewer resources.
Ultimately, whenever a spark of an ‘us versus them’ approach, across the primary-secondary care interface appears, it must be extinguished. Otherwise, it can turn into a wild fire that perpetuates resentment, dissatisfaction and animosity within the workforce, potentially leading to suboptimal patient care. Continuity has the potential to ameliorate every aspect of care provision. For instance, a functional system permitting direct conversations between clinicians, about patients for which they jointly-care, could burst the bubbles of individual silos and squash harmful stereotypes.
References
- Braunack-Mayer, A.J. (2006). The Ethics of Primary Health Care. In Principles of Health Care Ethics (eds R.E. Ashcroft, A. Dawson, H. Draper and J.R. McMillan). https://doi.org/10.1002/9780470510544.ch48
- About RCGP: Definition of a GP: Royal College of General Practitioners; 2023 [Available from: https://www.rcgp.org.uk/about]
- Khan N, What’s in a name? GPs as consultants in general practice, BJGPLife, Dec 4th 2023, https://bjgplife.com/whats-in-a-name-gps-as-consultants-in-general-practice/ [accessed 24/11/25]
Featured Photo by Bruno Justo Pego on Unsplash
